The Westchester Home on Spruce

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) B. Miranda & M. Vega conducted an unannounced visit today for the facility’s annual inspection. LPAs introduced themselves and was allowed entrance into the facility. LPAs met with Sally M. Jackson. Facility is licensed for 6 residents and has a current census of 4. There are 0 residents on hospice and 1 with a health care plan. Home Health plan is current. Water temperature was checked in the kitchen which read at 105 degrees Fahrenheit. Fire Extinguisher was purchased February 19, 2026 and is within the safety regulation period. Smoke and carbon monoxide detectors were tested and in working order. Facility has wrought iron gate that was not in place, when facility received fire clearance. Facility has a chain link lock at the top of a door leading to the backyard and a sliding lock on the top of the side door. In a common bathroom LPA observed broken tile in front of the toilet, bath tub stained, and no non-slip mat. Liability insurance is not current, expired May 2026. Rosanda J. Anderson Administrator's Certification expires June 26, 2026. Sally has been “Administrator” since January 2026, a written notice was not submitted to the Dept within 30-day. Staff files were reviewed, are complete, and current. Resident files were reviewed. Facility provided a log for disaster drills. Last drill was conducted in January 2026. First aid kit on site. Toxins and cleaning supplies are locked and inaccessible. There is a locked storage for medications. Medications were reviewed and not properly recorded. Facility does not have a centrally stored medication log for the residents. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms, bathrooms, medication storage, kitchen, garage, and outdoor areas. Bedrooms were clean, properly furnished, with adequate lighting, and in good repair. Food supply is adequate for 2-day perishable and 7-day nonperishable. Deficiencies observed were cited during today's inspection per California Code of Regulations, Title 22. LPA is requesting the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing by June 24, 2026. Exit interview conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Sally Jackson.the state’s words, verbatim · CDSS document, Jun 17, 2026

Type of visit: Office

On 05/20/2025, an informal meeting was held at the Fresno Regional Office. The purpose of the informal meeting was to discuss recently identified issues/concerns associated with the operation of the facility. The informal meeting process was explained during this meeting. The following were in attendance at this meeting: Licensee, Manjit Chauhan Licensee, Lakhwinder Kaur Administrator, Rosanda Anderson Licensing Program Manager I, Sergiy Pidgirny Licensing Program Manager I, Alexandria Walton Licensing Program Analyst, Melinda Medina During this meeting the following topics were discussed: Licensure of facility Accountability of licensee as a governing body Client Records Plan of Operation Food Service Fingerprint Clearance Fire Clearance In addition, on 04/08/2025 during an annual inspection at Westchester Home on Spruce and on 04/17/2025 during an annual inspection at Brighton Manor, LPA Medina and LPM Walton conducted interviews with staff. During the interviews, consistent statements from staff revealed that S1 has worked in the facilities and S1 has provided care to the residents. LPA checked the facility personnel report in LIS and found that S1 is not cleared to work in the facility. During this meeting, a deficiency is being cited in accordance with California Code of Regulations, Title 22, Division 6 on the attached 809D. An immediate civil penalty is hereby assessed in the amount of $500 for background clearance. Exit interview conducted. Plan of correction was developed and reviewed with the licensee. A copy of this report, civil penalty and appeal rights were discussed and provided to Licensees, Manjit Chauhan and Lakhwinder Kaur.the state’s words, verbatim · CDSS document, May 20, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: May 21, 2025

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department or ** This was not met as evidenced by S1 has been present in the facility and not fingerprint clearedthe state’s words, verbatim · CDSS document, May 20, 2025

Plan of correction: S1 to be fingerprinted by 5/21/25 and receive clearance prior to being present in the facility. Plan of correction must be submitted to Fresno Regional Office by close of business on 5/22/25.

Type of visit: Case Management - Other

On 4/17/2025, Licensing Program Analyst (LPA) M. Medina and Licensing Program Manager (LPM) A. Walton conducted an unannounced Case Management visit. LPA and LPM arrived, and allowed entry by Direct Care Staff. Designee, Shontina Kelly contacted by telephone and arrived a short time later to conduct case management visit with LPM and LPA. Facility tour conducted prior to designee arrival. LPA and LPM arrived to amend the annual inspection report from 4/08/2025 to include observations made while LPA and LPM were leaving facility on that date. LPA and LPM observed designated fire exit from backyard to street to be unlocked, Kitchen observed to have wrought iron gate in place but unlocked. LPA observed pin pad key pad still in place on front door but LPM was able to exit without code, security guard on the lower left corner to of door has been removed. No deficiencies cited during today's inspection..the state’s words, verbatim · CDSS document, Apr 17, 2025

Type of visit: Case Management - Annual Continuation

On 4/08/25, Licensing Program Analyst (LPA) M. Medina and Licensing Program Manager (LPM) A. Walton conducted an unannounced Annual Continuation visit to facility. LPM and LPA arrived, introduced self, stated purpose of visit, and allowed entrance by Caregiver. Designee, Rosanda Anderson, contacted by telephone and arrived a short time later to conduct facility visit. During last facility visit, Administrator on record was not present and LPA was informed that she had been absent from facility and had moved out of state to attend school. Prior to today's inspection, LPM Walton received a Administrator packet for Rosanda Anderson that is currently under review. Resident bedrooms toured, residents rooms are observed to have required furnishings, Resident bathroom toured, water temperature measured at 119 degrees F. Shower/Tub observed to have a non-skid mat and shower chair available. Kitchen observed to have a locked wrought iron gate making kitchen inaccessible to residents. The wrought iron gate was not in place, when facility received fire clearance. LPA observed facility has a 7-day supply of non-perishable food available or a 2-day supply of perishable food available. Medication reviewed and observed that 3 out of 5 residents did not receive medications due to medication being refilled. R1 has medication listed on physician's report, care plan, and hospital discharge paperwork, R1's medication is not on hand or listed on MARS or Centrally Stored Medication. Facility is unable to provide documentation for discontinuation of R1's medication. Staff and resident files reviewed. All staff files reviewed are missing proper documentation for training. Resident files were incomplete and did not contain Appraisal/Needs and Services Plans. Outside of facility toured. LPA observed shaded area with table but no adequate seating available. LPA observed several chairs in the backyard that need removal and/or replacement. Designated fire exit in back yard exiting to street was locked at time of inspection. As LPA and LPM were leaving facility on 4/08/2025, they observed the interior of front door of facility to have a pin pad that required a code to open front door to exit and a door security guard on the lower left corner to of door. There is a door latch on french doors leading to back patio that need to be removed. All deficiencies observed are being cited on the attached 809-D. Immediate Civil Penalty Assessed. Exit interview conducted. A copy of report provided to staff for facility records.the state’s words, verbatim · CDSS document, Apr 8, 2025

Type of visit: Required - 1 Year

On 3/28/2025, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required inspection. LPA arrived, introduced self, provided identification, and allowed entrance into facility by Direct Care Staff (S1). Staff contacted Rosanda Anderson by telephone, who arrived a short time later to conduct facility inspection with LPA. LPA observed facility to be clean, odor free, and a comfortable temperature. Currently, there are six (6) residents in care, all residents were present at time of inspection. LPA toured resident bedrooms and observed bedrooms to have required furnishings. Resident bathroom toured and observed to have grab bars, shower chair, and non-skid mat available. Water temperature measured at 110 degree F. Kitchen toured, LPA observed food in the refrigerator to be properly stored and labeled. LPA observed an adequate supply of food available for residents in care. Living room and family room have adequate seating available for residents. Dining areas have adequate seating available for residents. Fire extinguishers present with a service date of 3/20/25. Fire extinguisher and carbon monoxide detector present in facility and observed operational at time of inspection. Outside of facility toured, all exits open free of obstruction. Staff and resident files reviewed. Due to time constraints, LPA will return at a later time to complete inspection and inspection tool. Deficiencies, if any will be issued at completion of inspection.the state’s words, verbatim · CDSS document, Mar 28, 2025

Allegation investigated: Facility staff do not administer resident’s medications as prescribed

On 12/11/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct subsequent complaint investigation on the above allegation. LPA introduced self, stated the purpose of the visit and requested to meet with Administrator. LPA met with staff Anne Neri and staff Jacqueline tucker. Administrator Sundae Hill was called and arrived shortly. Complaint findings were delivered to Administrator. During the course of the investigation, residents’ medications were audit and MARs were reviewed, medications audit showed staff did not administered the residents’ medications as directed by physician. Based on observation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 6 are being cited on the attached LIC 9099D. An exit interview was conducted. A copy of this report and appeal rights were provided to the Administrator, whose signature on this form confirms receipt of this report. Substantiatedthe state’s words, verbatim · CDSS document, Dec 11, 2024 · control 24-AS-20240521121651

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Dec 12, 2024

87465(c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on observation, records reviewed, and interview conducted, residents’ medications were checked, and medications were observed not administered as directed by physician by staff, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 11, 2024

Plan of correction: Licensee shall submit documents of steps the facility will take to ensure facility meets the regulation. Statement will include staff in-service trainings, steps on administering medications, review of medications. Statement will be submitted to Fresno CCL office by POC due date 12/12/24. Licensee shall have all staff in-service trainings on medications regulations. Licensee will submit documentation of training topics including training date, training materials, training instructor name, and staff attendance rooster to the Fresno CCL office by 12/27/24.

Type of visit: Case Management - Deficiencies

On 12/11/24, Licensing Program Analyst (LPA) M. Yang arrived to conduct an unannounced subsequent complaint investigation and met with Administrator Sundae Hill. During the course of the complaint investigation, interviews were conducted and residents’ medications were checked. Centrally Stored Medication Record and Medications Administration Record (MAR) was reviewed. Technical Support Program (TSP) assistance was offered to Administrator. Administrator will make a decision and reach out the department regarding acceptance. Deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6. An exit interview was conducted. A copy of this report and appeal rights were provided to Administrator, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Dec 11, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(5) · Plan of correction due date: Dec 12, 2024

87465(h)(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement was not met as evidenced by: Based on observation, LPA checked R1’s medication with Administrator present. LPA observed in R1’s Furosemide 20 mg medication bottle, 5 capsule that were different size stored in with the Furosemide tablets which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 11, 2024

Plan of correction: The five small capsule was immediately removed by Administrator. Licensee shall submit documents of steps the facility will take to ensure facility meets the regulation which will include ensuring that all medications are stored in original container with no other medications. Statement will submit to Fresno CCL office by POC due date 12/12/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6) · Plan of correction due date: Dec 17, 2024

87465(h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year. This requirement was not met as evidenced by: Based on interviews conducted and records reviewed, there are no Centrally Stored Medication Record (Lic 622) on file for all four residents, which poses/ posed a potential health, safety, or personal rights risk for the person in care.the state’s words, verbatim · CDSS document, Dec 11, 2024

Plan of correction: Licensee shall ensure that all residents have Lic 622 on file and up to date. Copy of Lic 622 for all 4 residents will be submitted to Fresno CCL by POC due date 12/17/24.

Type of visit: Case Management - Other

On 11/19/2024, Licensing Program Analysts (LPAs) Walton and Medina arrived unannounced to conduct a case management inspection. LPAs introduced themselves, stated the purpose of the visit and requested to meet with the Administrator. LPAs were granted entry to the facility by facility staff. Staff contacted Administrator, Sundae Hill, who arrived a short time later. LPAs met with Administrator. The purpose of today's visit is to follow up on information submitted to the Fresno CCL office. LPAs conducted a health and safety check, reviewed facility records and interviewed staff and residents during today's inspection. LPAs will return at a later date to address concerns observed during today's inspection. No deficiencies issued during today's visit. Exit interview conducted. A copy of this report was discussed and provided to Administrator, Sundae Hill, whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Nov 19, 2024

Type of visit: Required - 1 Year

Today, Licensing Program Analyst L. Xiong arrived at the facility unannounced to conduct the Annual Inspection. LPA met with staff Sandra Jacobo and Administrator/Licensee Lakhwinder Kaur and inform her the purpose of the visit. LPAs observed a central entry point with a supply of hand sanitizer and a sign in policy that includes documented routine symptom screening for resident's, staff and visitors. LPA introduced self and allowed entrance by staff. All COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Licensee brought records for review and staff provided facility tour for LPA. Facility appeared clean with no obstruction or fire clearance issues. All common areas have adequate seating and lighting. Resident bedrooms toured, rooms observed to have all required accommodations. Kitchen toured, LPA observed a 2-day supply of perishable and a 7-day supply of non-perishable food available for residents. Smoke detector and carbon monoxide detectors observed operational during inspection. Fire extinguisher present with a service date of 12/2023. Water temperature observed to measure at 105 degrees F. No deficiencies were observed.the state’s words, verbatim · CDSS document, Feb 20, 2024

Type of visit: Case Management - Annual Continuation

On 11/20/23 at 11:29 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry by staff. Licensees (LIC) Manjit Chauhan arrived a short time later. LPA conducted a tour of the facility and completed the Inspection Tool. The following deficiency was observed by LPA: 1. Med (Medication) cart was observed unlocked and accessible; and a bottle of toilet cleaner was observed accessible and stored in cabinet under bathroom sink in first hall bathroom. Deficiency is being cited based on LPA observations in accordance with the California Code of Regulations, Title 22, see LIC809D. An immediate civil penalty is being assessed in the amount of $1000 for a repeat violation of CCR 87309(a). See LIC421IM for more details. Exit interview conducted. A copy of this report and appeal rights were given to Licensee Manjit Chauhan, whose signature confirms receipt of this report. A Plan of Correction was reviewed and developed with Licensee. The following updated forms are to be submitted within two weeks: LIC610E, LIC9020, LIC500, LIC308the state’s words, verbatim · CDSS document, Nov 20, 2023

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.